The OptiMA protocol in children with wasting and stunting
Authors: Gabriele Rossi
Journal: The Lancet Global Health (2022)

In their open-label, non-inferiority, randomised controlled trial, Cécile Cazes and colleagues (April, 2022)1Cazes C Phelan K Hubert V et al.Simplifying and optimising the management of uncomplicated acute malnutrition in children aged 6–59 months in the Democratic Republic of the Congo (OptiMA-DRC): a non-inferiority, randomised controlled trial.Lancet Glob Health. 2022; 10: e510-e520Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar assessed the efficacy, safety, and cost implications of a single protocol for moderate acute and severe acute malnutrition management, using only ready-to-use therapeutic food (RUTF) at a decreasing dose as weight and mid-upper-arm circumference (MUAC) increase (OptiMA strategy) in the Democratic Republic of the Congo. The authors found that the OptiMA strategy was superior to standard treatment in terms of favourable outcomes (recovery and relapse rates) 6 months after programme enrolment. According to the authors, the study “suggests that [OptiMA] is safe, feasible, and beneficial to treat children with a MUAC of less than 125 mm or oedema with RUTF as a single nutritional supplement, adapting the initial dosage to the degree of acute malnutrition by progressively decreasing the dose as MUAC and weight increase”. In a previous single-arm proof-of-concept OptiMA trial,2Daures M Phelan K Issoufou M et al.New approach to simplifying and optimizing acute malnutrition treatment in children aged 6–59 months: the OptiMA single-arm proof-of-concept trial in Burkina Faso.Br J Nutr. 2020; 123: 756-767Crossref PubMed Scopus (13) Google Scholar done in Yako district, Burkina Faso in 2017, outcomes were stratified by MUAC category at the time of nutrition programme admission. The recovery rate was lowest (64·3%) for children admitted with a MUAC of less than 115 mm and a weight-for-height Z score of less than –3, and was driven primarily by a high non-response rate (12·5%). Stunting was also highly prevalent in this group, reaching 57·9%.2Daures M Phelan K Issoufou M et al.New approach to simplifying and optimizing acute malnutrition treatment in children aged 6–59 months: the OptiMA single-arm proof-of-concept trial in Burkina Faso.Br J Nutr. 2020; 123: 756-767Crossref PubMed Scopus (13) Google Scholar A similar trial3UNICEFTreatment of wasting using simplified approaches—a rapid evidence review.https://www.unicef.org/media/97006/file/Simplified-Aproaches-Rapid-Evidence-Review.pdfDate: 2020Date accessed: March 20, 2022Google Scholar in Mirriah district, Niger showed that 92·1% of children who were non-respondents were also stunted. Given these findings, it would be reasonable to analyse the effect of OptiMA in the category of clinically vulnerable children presenting with a combination of wasting and stunting.4Myatt M Khara T Schoenbuchner S et al.Children who are both wasted and stunted are also underweight and have a high risk of death: a descriptive epidemiology of multiple anthropometric deficits using data from 51 countries.Arch Public Health. 2018; 76: 28Crossref PubMed Scopus (67) Google Scholar In the current study, although patients in the standard treatment group showed an almost statistically significant higher presence of severe stunting (ie, height-for-age Z score <–3) than patients in the OptiMA group (p=0·057), it is not possible to assess whether most of the severely stunted children were concentrated within the category of severe acutely malnourished children or were equally distributed between those with severe acute malnutrition and those with moderate acute malnutrition. Indeed, an absence of homogeneity in the proportion of children with wasting and stunting in the standard treatment group versus in the OptiMA group could affect the overall outcome results, particularly for the children in the severely acutely malnourished category. I declare no competing interests. Simplifying and optimising the management of uncomplicated acute malnutrition in children aged 6–59 months in the Democratic Republic of the Congo (OptiMA-DRC): a non-inferiority, randomised controlled trialIn this non-inferiority trial treating children with MUAC of less than 125 mm or oedema, decreasing RUTF dose according to MUAC and weight increase proved to be a superior strategy to the standard protocol in the Democratic Republic of the Congo. These results demonstrate the safety and benefits of an approach that could substantially increase access to treatment for millions of children with acute malnutrition in sub-Saharan Africa. Full-Text PDF Open AccessThe OptiMA protocol in children with wasting and stunting – Authors' replyAuthors' reply We fully agree with Gabriele Rossi that the evaluation of simplified protocols aimed at optimising the management of uncomplicated acute malnutrition in children should include analyses dedicated to the most clinically vulnerable children. This is exactly the reason why the OptiMA-DRC trial was done in two stages. Beyond the evaluation already reported1 in the entire population of children presenting with acute malnutrition, defined as a mid-upper-arm circumference (MUAC) of less than 125 mm, a weight-for-height Z score (WHZ) of less than –3, or oedema, we then continued to enrol children with a MUAC of less than 115 mm, a WHZ of less than –3, or an oedema at baseline, so that we had enough statistical power to compare across study groups the proportion of children who met the WHO definition of severe acute malnutrition2 who recovered. Full-Text PDF Open Access